Acute geriatrics at the front door.

Older people with frailty and urgent care needs are major uses of health and social care services. Comprehensive geriatric assessment (CGA) is an evidence-based approach to improving their outcomes, as well as improving service outcomes. Geriatricians form a small proportion of the overall workforce and cannot address the population need alone, so all clinicians (doctors, nurses, therapists and so on) need to engage in delivering CGA as a process of care, underpinned by specific competencies - which can be developed. Delivery of this care pathway needs to be measured and improved as rigorously as campaigns like those for improving sepsis or eradicating methicillin-resistantStaphylococcus aureus

Improving outcomes for older people with emergency care needs

This article describes work on emergency care for older people. It summarises patient experience in emergency care settings, the evidence base relating to improvement of outcomes and emerging interventions and describes tools that can support teams as they work on service improvement. Finally, it calls for the measurement of outcomes that matter to older people, as a mechanism to drive more person-centred approaches to emergency care

The challenges of using the Hospital Frailty Risk Score - Author's reply

We thank John Soong and colleagues, Sandra M Shi and Dae H Kim, and Rónán O'Caoimh and colleagues for their careful consideration of our Article. We note some concerns about the clinical utility of our scoring method; our approach is to position the Hospital Frailty Risk Score (HFRS) as a tool that can be implemented without the need for additional assessment or data collection, and direct high-risk individuals towards frailty-attuned interventions, such as the Comprehensive Geriatric Assessment (CGA).1 We acknowledge that the HFRS can only be generated after an initial admission, so risk stratification information would not be possible at first presentation. Two-thirds of people aged 75 years or older access acute-care hospitals more than once over a 2-year period, and those patients who have not previously accessed hospital care are typically at low risk of hospital-related adverse outcomes; thus, we view the HFRS as being especially useful to identify individuals at the highest risk of hospital-related harm and resource use. We accept that manual scales, such as the Clinical Frailty Scale,2 could be used, but the HFRS has the advantage of being automated and capturing all patients, not just a selected sample

Geriatric emergency medicine: time for a new approach on a European level.

Editorial Throughout Europe, the older population is increasing. Of the 551 million inhabitants, 19.4% were of 65 years and over in 2017, it is expected that in 2040 that number will rise to 27%[1]. With increasing age, there is an increased risk of disease and both are associated with increasing Emergency Department attendances. But although EDs are well organised environments in which effective and cost-effective emergency care is delivered 24/7, it is questionable whether older patients, especially those with frailty, optimally benefit from this care the way it is currently organised [2]. Older patients living with frailty may present with syndromes such as delirium and falls. Compared to younger patients, older patients are at high risk of adverse outcomes such as admission, readmission, institutionalisation and death [3]. For older patients, other outcomes such as functional decline may be even more important. But evidence on how to treat older patients is lacking, as older patients are often excluded from clinical studies and specific frailty syndromes are not reported, even in trials designed specifically for this patient group.[4, 5]

What are the goals of care for older people living with frailty when they access urgent care? Are those goals attained? A qualitative view of patient and carer perspectives

Study objective: Little is known of the goals of care of older people living with frailty when they access urgent care. Equally whether these goals are attained from a patient and carer perspective is often unclear. This qualitative study examined the views of older people living with frailty and their families in relation to specific episodes of urgent care, what they wanted to achieve and whether those goals were attained. Methods: Semi-structured interviews with older people living with frailty and their families between Jan and July 2019. Patient and carer participants were recruited in three hospitals in England and interviewed following the urgent care episode. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach. Results were validated by an older people's involvement group. Results: Forty participants were interviewed either alone or jointly (24 patients and 16 carers), describing episodes of urgent care which started in ED for 28 patients. The goals of care for participants accessing emergency care were that their medical problem be diagnosed and resolved; information about tests and treatment be given to them and their relatives; they receive an appropriate well-planned discharge to their own home with support where needed and without readmission or re-attendance at ED; and that they retain mobility, function and normal activities. Participants perceived that many of these goals of care were not attained. Conclusions: Older people living with frailty have heterogeneous urgent care goals which require individual ascertainment. Identifying these goals of care early could result in improved attainment through person-centred care

Frailty factors and outcomes in vascular surgery patients: a systematic review and meta-analysis

Objective To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes. Background Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken. Methods Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO and Scopus. Quality of studies was assessed using Newcastle Ottawa scores (NOS) and quality of evidence using GRADE criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RR), and associations with outcomes expressed as odds ratios (OR) or hazard ratios (HR). Data were pooled using random effects models. Results Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age (MD 4.05 years; 95% confidence interval [CI] 3.35, 4.75), female sex (RR 1.32; 95%CI 1.14, 1.54), and lower body-mass index (MD -1.81; 95%CI -2.94, -0.68). Frailty was associated with 30-day mortality (adjusted [A]OR 2.77; 95%CI 2.01-3.81), post-operative complications (AOR 2.16; 95%CI 1.55, 3.02) and long-term mortality (HR 1.85; 95%CI 1.31, 2.62). Sarcopenia was not associated with any outcomes. Conclusion Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.</div

Co-producing Progression Criteria for Feasibility Studies: A Partnership between Patient Contributors, Clinicians and Researchers.

There is a lack of guidance for developing progression criteria (PC) within feasibility studies. We describe a process for co-producing PC for an ongoing feasibility study. Patient contributors, clinicians and researchers participated in discussions facilitated using the modified Nominal Group Technique (NGT). Stage one involved individual discussion groups used to develop and rank PC for aspects of the trial key to feasibility. A second stage involving representatives from each of the individual groups then discussed and ranked these PC. The highest ranking PC became the criteria used. At each stage all members were provided with a brief education session to aid understanding and decision-making. Fifty members (15 (29%) patients, 13 (25%) researchers and 24 (46%) clinicians) were involved in eight initial groups, and eight (two (25%) patients, five (62%) clinicians, one (13%) researcher) in one final group. PC relating to eligibility, recruitment, intervention and outcome acceptability and loss to follow-up were co-produced. Groups highlighted numerous means of adapting intervention and trial procedures should 'change' criteria be met. Modified NGT enabled the equal inclusion of patients, clinician and researcher in the co-production of PC. The structure and processes provided a transparent mechanism for setting PC that could be replicated in other feasibility studies

Leg Ischaemia Management collaboration (LIMb): study protocol for a prospective cohort study at a single UK centre

Introduction Severe limb ischaemia (SLI) is the end-stage of peripheral arterial occlusive disease where the viability of the limb is threatened. Around 25% of patients with SLI will ultimately require a major lower limb amputation which has a substantial adverse impact on quality of life. A newly established rapid-access vascular limb salvage clinic and modern revascularisation techniques may reduce amputation rate. The aim of this study is to investigate the 12-month amputation rate in a contemporary cohort of patients and compare this to a historical cohort. Secondary aims are to investigate the use of frailty and cognitive assessments, and cardiac MRI in risk-stratifying patients with SLI undergoing intervention and establish a biobank for future biomarker analyses. Methods & analysis This single-centre prospective cohort study will recruit patients aged 18-110 years presenting with SLI. Those undergoing intervention will be eligible to undergo additional venepuncture (for biomarker analysis) and/or cardiac MRI. Those aged ≥65 years and undergoing intervention will also be eligible to undergo additional frailty and cognitive assessments. Follow-up will be at 12 and 24 months and subsequently via data-linkage with NHS digital to 10 years post-recruitment. Those undergoing cardiac MRI and/or frailty assessments will receive additional follow-up during the first 12 months to investigate for peri-operative myocardial infarction and frailty related outcomes, respectively. A sample size of 420 patients will be required to detect a 10% reduction in amputation rate in comparison to a similar sized historical cohort, with 90% power and 5% type-I error rate. Statistical analysis of this comparison will be by adjusted and unadjusted logistic regression analyses. Ethics & dissemination Ethical approval for this study has been granted by the UK National Research Ethics Service (19/LO/0132). Results will be disseminated to participants, via scientific meetings, peerreviewed medical journals and social media. Study registration ClinicalTrials.gov [NCT04027244